Hospital Emergency On-Call Coverage: Is There a Doctor in the House?

Issue Brief No. 115

November 2007

Ann S. O'Malley, Debra A. Draper, Laurie E. Felland

Community hospitals across the United States are encountering mounting difficulties in obtaining emergency on-call coverage from specialist physicians, based on findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan areas. The declining willingness of specialists to participate in on-call rotations comes at a time when hospital emergency departments are experiencing steadily rising demand for services. Several factors contribute to physicians' reluctance to provide on-call coverage, including reduced reliance on hospital admitting privileges as more procedures migrate to non-hospital facilities; concerns about compensation for emergency care, particularly for uninsured patients; and anxieties surrounding medical liability. In response, hospitals have adopted strategies such as enforcing medical staff bylaws that mandate call participation, entering into contracts with physicians to guarantee coverage, offering stipend payments, and directly employing specialists. Despite these efforts, many hospitals continue to face insufficient on-call coverage, jeopardizing patients' timely access to high-quality emergency care and potentially driving up health care expenditures.

Pressures Intensify for Hospital Emergency Departments

Across the 12 HSC communities, the longstanding expectation that physicians accept emergency call duties as a condition of hospital admitting privileges is breaking down, creating risks that both insured and uninsured patients may not receive timely and appropriate treatment (see Data Source). Emergency on-call coverage means having a physician with the relevant specialty expertise available around the clock to care for patients. While sufficient on-call emergency coverage is primarily a concern for hospital emergency departments (EDs), it is also becoming an increasing challenge for hospitalized patients who require urgent specialist consultation.

Two years earlier, HSC researchers documented the array of pressures confronting hospital EDs -- pressures that persist today and continue to hamper hospitals' ability to maintain adequate emergency on-call coverage.[1] Chief among these pressures is a surge in demand for emergency services that exceeds the rate of population growth. Over the previous decade, the overall rate of ED utilization had climbed 7 percent, rising from 36.9 to 39.6 visits per 100 persons.[2] Managing the efficient movement of patients through the hospital -- commonly referred to as throughput -- also remains an ongoing challenge, and delays in accessing specialty services contribute to overcrowding as ED patients wait for a specialist to evaluate them.

Although insured individuals account for the overwhelming majority of ED visits in the United States, the share of visits by uninsured patients is climbing at a comparatively faster rate. Self-pay or uninsured patients represented 14 percent of ED visits in 2003, a figure that rose to 16 percent by 2005.[3] Respondents across all 12 communities primarily attributed this increase to the expanding ranks of uninsured individuals, including immigrants.[4] As one Cleveland hospital chief financial officer observed, "The uninsured are utilizing our ED more frequently because they are finding it increasingly difficult to get appointments in private physician offices, largely because of a heightened emphasis on payment in those practices."

Growing Reluctance to Take Call

Although this has been a persistent problem for the past decade, recent accounts from hospital executives and other market observers in the 12 communities point to a deteriorating situation when it comes to hospitals' capacity to secure emergency on-call coverage, intensifying friction between hospitals and physicians. As one Seattle market observer remarked, "I believe the ED coverage-of-care issue is far more prominent than it was two years ago. We've convened numerous meetings about distributing the responsibility across the city, and the problem continues to worsen." At the national level, 73 percent of emergency departments report that their on-call coverage by specialist physicians is inadequate.[5] Specialists who prove especially challenging to recruit for on-call duties include orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists, according to hospital executives.

In certain instances, a shortage of specific specialists contributes to gaps in on-call coverage. However, physician unwillingness to accept call appears to be a more critical issue for many hospitals, compounding broader workforce challenges in which physicians are not selecting specialties or practice locations that align well with the medical needs and geographic distribution of the population.[6] A Little Rock hospital executive, for instance, noted, "There are plenty of neurosurgeons. They are all trying to figure out how to avoid ER call, which creates an artificial shortage."

Why Specialty Physicians Avoid Taking Call

Historically, physicians accepted on-call emergency duty in return for hospital admitting privileges, which enabled them to connect with new patients and build their practices. In addition, the substantial public subsidization of medical education and residency training has long been accompanied by an implicit social contract obligating physicians to uphold the core competencies of their specialty at hospitals where they practice and to contribute to emergency call coverage.[7] Hospitals enforce these on-call requirements through medical staff bylaws or other contractual arrangements with physicians. As many specialists now redirect the focus of their practices away from general hospital settings or toward specialty hospitals that lack emergency departments, they have become less dependent on hospital admitting privileges to treat their patients or sustain a viable practice.

Compensation for emergency care, and for physician services more broadly, represents another significant factor behind specialists' resistance to providing on-call coverage. Many physicians regard the payment they receive for care delivered while on call as insufficient, and when they are expected to treat uninsured patients, the financial burden becomes especially difficult to bear. Time that a physician spends evaluating ED patients carries an opportunity cost in terms of time away from insured patients in their office-based practice. As one Syracuse hospital executive explained, "They [physicians] view ED call as a burden. It adversely affects both quality of life and finances."

Specialists are also worried that delivering ED care heightens their exposure to medical liability and could lead to increased malpractice premiums. A Lansing physician observed, "Across the country, there is a widespread unwillingness among physicians to accept ER call. It certainly relates to the lack of reimbursement, but also to the malpractice issue. Large trauma cases and more complex cases typically carry greater risk -- that is the perception, at a minimum."

Furthermore, the trend toward so-called microspecialization among physicians -- for example, an orthopedist who concentrates exclusively on hand surgery -- has compounded the reluctance of surgeons to provide on-call coverage for more common emergency conditions they consider outside their narrow subspecialty focus. A Phoenix market observer lamented, "Now, we have highly specialized specialists and, because of liability concerns, they do not want to venture outside of their particular area." Despite this trend, given training requirements, the majority of specialists possess the foundational competencies that qualify them to manage the bulk of routine yet urgent conditions presenting in a general hospital.[8]

Quality-of-life considerations also shape physicians' resistance to providing emergency on-call coverage. Many physicians find on-call duty unappealing because it demands 24-hour availability. During daytime hours, this may require physicians to step away from their practice to respond to an emergency call. In the evenings or on weekends, call responsibilities can conflict with family obligations and other personal commitments.

Adverse Patient Outcomes

Evidence indicates that specialist physicians' resistance to providing emergency on-call coverage is contributing to negative patient outcomes. Twenty-one percent of patient deaths or permanent injuries connected to ED treatment delays are attributed to the unavailability of physician specialists.[9] Across the 12 communities, market observers reported that ED patients are experiencing longer waits for specialty care.

In some communities, routine specialty care is entirely unavailable in the emergency department, compelling patients to either travel considerable distances or be transferred to another hospital for relatively straightforward but urgent needs, such as uncomplicated fractures. In Little Rock, a hospital respondent recounted the case of a patient with hand injuries who had to be transported to another state for treatment because a specialist was not readily available. Such circumstances can lead to prolonged patient suffering and inconvenience, and in some instances result in a second ED visit and an additional ambulance bill. Two-thirds of ED directors at level I and II trauma centers report that more than half of all patient transfers they receive originate from a lack of timely access to specialist physicians at the referring hospital.[10]

The specialist on-call coverage challenge also places a disproportionate burden on physicians who are willing to provide coverage, heightening the risk of adverse patient outcomes as workloads grow and morale deteriorates. As fewer physicians agree to participate in call rotations, specialists who do provide on-call coverage in some regions must serve multiple hospitals on the same night. One Seattle ED director characterized this as "a tremendous strain" on physicians, adding: "Specialists feel that they committed to covering one hospital and now they have responsibility for all of them."

How Hospitals Secure Emergency Coverage

Hospitals are employing a range of strategies to obtain specialist emergency on-call coverage, including enforcing hospital bylaws that mandate call participation, compensating physicians for on-call coverage, covering professional fees for patients unable to pay, and implementing other administrative arrangements designed to improve the physician work environment.

Advances in medical technology, combined with the rise of physician-owned surgery centers, imaging facilities, diagnostic labs, and other outpatient venues, have driven the migration of many services out of the hospital setting. As a result, numerous specialists no longer require general hospital admitting privileges to maintain a thriving practice. Nevertheless, in certain markets, hospitals still retain enough leverage to enforce medical staff bylaws compelling physicians to accept on-call duties. A Little Rock health plan, for example, mandates that physicians -- as a condition of network participation -- maintain the highest level of hospital privileges, including providing on-call emergency coverage, unless the physician practices primarily as an office-based primary care provider. A plan respondent stated, "We continue to believe in call coverage for specialties. We believe that the oversight inherent in the hospital setting, peer review, and collegial interaction among peers benefits quality." A Miami hospital ED director reported that his institution's medical staff bylaws require physicians to arrive within an hour for a consult; otherwise, the CEO contacts them directly.

Some hospitals are obtaining emergency on-call coverage through contracts with physician groups that assume responsibility for ensuring emergency availability. This model is used in some areas experiencing rapid population growth and few medical training programs, such as Phoenix, but it is also employed in smaller cities, such as Syracuse, where directly hiring specialists may not be practical.

Certain hospitals provide particular specialists with a monthly or daily stipend for accepting on-call duties. A recent national survey revealed that 36 percent of hospitals compensated at least one type of specialist, most commonly a general surgeon, for taking ED call.[11] Some hospital respondents find that offering stipends or other forms of compensation in a competitive marketplace is more politically feasible than enforcing medical staff bylaws. One Miami hospital engaged an external consultant to establish a fair-market stipend rate for physicians providing emergency on-call coverage. The hospital parted ways with physicians who demanded more than the prevailing rate and instead brought on employed physicians in those specific specialties. A Little Rock hospital pays trauma surgeons $1,000 per night for coverage. Hospitals in many of the other 12 communities reported comparable experiences for certain specialists, most frequently orthopedic, trauma, and general surgeons. Compensating specialists for on-call emergency coverage reportedly costs one Miami hospital $10 million annually.

In addition to the substantial costs associated with paying physicians for emergency call, some hospitals worry about potential conflicts with the federal anti-kickback law, which prohibits any inducement for referrals of items or services reimbursable by a federal health care program. In a recent advisory opinion, the U.S. Health and Human Services Office of Inspector General indicated that hospital payments to physicians for emergency on-call coverage could potentially run afoul of the anti-kickback statute. In the specific arrangement described in the advisory opinion, however, the Office of Inspector General determined that sufficient safeguards existed to prevent the arrangement from being used to induce referrals.[12]

Instead of stipends -- and increasingly in combination with them -- some hospitals pay physicians for each uninsured patient they treat while on call. For instance, hospitals in Little Rock and Miami reported compensating physicians at no less than Medicare rates for patients lacking coverage. An Orange County hospital guarantees physicians Medicare rates plus 20 percent for treating certain uninsured patients.

A growing number of hospitals are moving past contractual or stipend-based arrangements toward directly employing specialist physicians. Beyond securing on-call coverage, hospital employment of specialists may form part of a broader service-line competitive strategy. An Indianapolis hospital chief medical officer stated, "I expect that most large hospital systems will employ more specialists. I believe that hospital systems would rather employ than subsidize." In doing so, however, hospitals must be careful to manage tensions with community-based specialists, who remain a significant source of referrals. As one Boston physician noted, "Hospitals are employing physicians, who in turn are taking patients from physicians in private practice. And then they are asking private-practice doctors to cover the ER at high risk with no compensation." One Phoenix hospital employs neurosurgeons, plastic surgeons, and trauma surgeons directly, but for political considerations, initially offered emergency on-call duties to private physicians and permitted them to decline. Because public hospitals and large academic medical centers with training programs often have many employed physicians, including residents and fellows who can provide emergency coverage, the ED coverage issue tends to be less severe for these institutions than for community hospitals.

A handful of hospitals in the 12 communities are pursuing alternative administrative arrangements to incentivize physicians to accept ED call. A Little Rock hospital provides practice management support and seeks to identify mutually beneficial arrangements to encourage physicians to take call rather than offering additional monetary compensation. One such arrangement involves collaborating with orthopedic surgeons to develop more surgeon-friendly operating room schedules in exchange for ED call coverage. A Miami hospital channels compensation for physicians' on-call time into a tax-deferred investment account that vests after five years as life insurance. Other hospitals cover physicians' malpractice premiums in return for on-call coverage or cross-subsidize premiums as a means of maintaining on-call specialty services.

Implications

The escalating difficulty hospitals face in obtaining emergency on-call coverage from specialist physicians endangers all patients' access to high-quality emergency care in local communities, irrespective of insurance status. Insufficient on-call coverage creates conditions ripe for poor quality of care and adverse patient outcomes. Moreover, some approaches to addressing the on-call emergency coverage gap -- such as stipend payments -- add significant costs to the system.

The varied strategies hospitals employ to mitigate the on-call coverage problem are not a comprehensive solution. A failure to address the root causes of the crisis -- market dynamics that discourage specialist physicians from providing emergency on-call coverage, including reimbursement structures that steer them toward the higher revenues available in outpatient and specialty hospital settings, the growing population of uninsured individuals, and the elevated costs of medical malpractice insurance -- is likely to make the situation worse, generating additional quality and cost pressures throughout the health care system.

Notes

1. O'Malley, Ann S., et al., Rising Pressure: Hospital Emergency Departments as Barometers of the Health Care System, Issue Brief No. 101, Center for Studying Health System Change, Washington, D.C. (November 2005).

2. Nawar, E.W., R.W. Niska and J. Xu. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary, Advance Data from Vital and Health Statistics, No. 386. National Center for Health Statistics, Hyattsville, Md. (2007).

3. Nawar 2007; McCaig, Linda F., and Catharine W. Burt. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary, Advance Data from Vital and Health Statistics, No. 358, National Center for Health Statistics, Hyattsville, Md. (2005).

4. Draper, Debra A., and Paul B. Ginsburg. Health Care Cost and Access Challenges Persist: Initial Findings from HSC's 2007 Site Visits. Issue Brief No. 114, Center for Studying Health System Change, Washington, D.C. (October 2007).

5. "On-Call Specialist Coverage in U.S. Emergency Departments," American College of Emergency Physicians (ACEP), Irving, Texas (April 2006).

6. Caffee, Hollis, and Chad Rudnick. "Access To Hand Surgery Emergency Care," Annals of Plastic Surgery, Vol. 58, No. 2 (February 2007).

7. Bosse, Michael J., et al., "Access to Emergent Musculoskeletal Care: Resuscitating Orthopaedic Emergency Department Coverage," Journal of Bone and Joint Surgery, Vol. 88A, No. 6 (June 2006).

8. Ibid.

9. Sentinel Event Alert, No. 26, The Joint Commission (June 17, 2002). http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm, accessed Sept. 6, 2007.

10. ACEP 2006.

11. ACEP 2006.

12. U.S. Department of Health and Human Services, Office of Inspector General, Advisory Opinion No. 07-10 (Sept. 27, 2007).

Data Source

Every two years, HSC conducts site visits in 12 nationally representative metropolitan communities as part of the Community Tracking Study, interviewing health care leaders about the local health care market and how conditions have evolved. The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Approximately 500 interviews were carried out between February and June 2007 across the 12 communities with representatives of health plans, hospitals, physician organizations, major employers, benefit consultants, insurance brokers, community health centers, consumer advocates, and state and local policy makers. In each community, representatives from at least two of the larger hospitals were interviewed. Hospital representatives included the chief executive officer, chief financial officer, chief medical officer, medical staff president, and at some hospitals, the emergency department director.

Sources and Further Reading

CDC: Emergency Department Visit Data — National Center for Health Statistics data on emergency department utilization trends cited in this research.

CMS: Emergency Medical Treatment and Labor Act (EMTALA) — Federal regulations governing hospital emergency department obligations, including requirements for on-call specialist availability.

HHS Office of Inspector General Reports — Federal oversight reports on hospital compliance and physician compensation arrangements, including emergency on-call coverage advisory opinions.

AHRQ: Emergency Care Research — Federal research on emergency care quality, patient outcomes, and hospital throughput challenges discussed in this study.

AMA Physician Workforce Data — American Medical Association data on physician specialty distribution and workforce trends affecting emergency on-call coverage.